Round Ligament Research Articles

Laparoscopic Pectopexy with Burch Colposuspension for Pelvic Prolapse Associated with Stress Urinary Incontinence

To present a case of pelvic organ prolapse associated with stress urinary incontinence treated by laparoscopic pectopexy followed by Burch colposuspension. Case report. University Gynecology Clinic of the Emergency Clinical City Hospital Timișoara, Romania. We present the case of a 41-year-old woman, gravida 1 para 1, with no notable medical or surgical history, with a body mass index of 40 kg/m2, who presented in our service with heavy menstrual bleeding, dysmenorrhea, pelvic pressure, dyspareunia, stress urinary incontinence, and voiding difficulties. Local examination revealed a cervix descended 2 cm below the hymenal ring, cystocele, urethrocele, and a positive cough stress test. The pelvic prolapse was classified as pelvic organ prolapse quantification stage 3. Ultrasound exam revealed a uterus with diffuse adenomyosis of the posterior uterine wall and normal adnexa. Because of the patient's obesity, the treatment plan was laparoscopic supracervical hysterectomy for the treatment of adenomyosis, laparoscopic pectopexy for the correction of the apical defect, and Burch colposuspension for the cure of stress incontinence. The patient was placed in the standard dorsal lithotomy position with the hips in extension and the knees flexed and the table in 45° Trendelenburg position. One 10-mm umbilical optical trocar and three 5-mm trocars were used-2 inserted 2 cm above and medial to the anterior superior iliac crests, and the third, 5 cm below the umbilical trocar. The dissection started on the left side of the pelvis. The peritoneum was incised in the center of a V-shaped area bordered by the left round ligament and the obliterated umbilical artery (the medial umbilical ligament). The soft tissue was dissected, and the left iliopectineal ligament (also known as the inguinal ligament of Cooper) was identified right under the external iliac vein and prepared. The same steps were repeated on the right side of the pelvis. The procedure continued with the dissection of the vesicovaginal space. The anterior vaginal wall was exposed with the help of a retractor placed inside the vagina and held by an assistant. A supracervical hysterectomy was performed. An 8 × 15-cm polypropylene mesh, cut in a T shape, was introduced in the abdomen. First, the short arm of the T was fixed on the anterior vaginal wall using multiple absorbable tacks (AbsorbaTack fixation device; Medtronic, Dublin, Ireland). To use a type of nonabsorbable fixation, we decided to also fix the mesh to the cervix stump with 3 isolated stitches (Silk Suture 2-0; Ethicon, Somerville, NJ). Second, with the purpose of ensuring a permanent fixation, the lateral arms of the mesh were attached to the iliopectineal ligaments with multiple nonabsorbable tacks on both sides (ProTack fixation device; Medtronic, Dublin, Ireland). The procedure continued with the complete closure of the peritoneum with VICRYL 2-0 sutures (Ethicon). Because the patient also had stress urinary incontinence, a Burch colposuspension was performed. To expose its limits, the urinary bladder was filled with 200 mL of saline. After the incision of the peritoneum, the avascular space of Retzius was opened. The dissection continued until the Cooper's ligaments were exposed bilaterally. The proper suture placement points on the vaginal wall were facilitated by an assistant's intravaginal finger. Two isolated nonabsorbable silk stitches (Silk Suture 2-0) were placed through the Cooper's ligament and through the anterior vaginal wall on each side. The knots were tied just enough to properly lift the vaginal wall in the normal position, assessed by the assistant by vaginal route, but not too tight to avoid urethral obstruction. The duration of the surgery was 95 minutes, with minimal blood loss of about 60 mL. The patient recovered well, with the Foley catheter being removed after 12 hours. The patient was discharged after 48 hours. The 6-month follow-up examination revealed a correct anatomical position of the anterior vaginal wall and of the cervix at 6 cm above the hymenal ring and no urinary incontinence. Laparoscopic pectopexy represents a new option for the treatment of pelvic organ prolapse. In the case we reported, no intraoperative or postoperative complications were present, and the follow-up assessment revealed an effective correction of the prolapse. Further studies are needed to conclude the efficiency and safety of this new procedure.

Network meta-analysis comparing techniques and outcomes of stump closure after distal pancreatectomy.

The incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy remains high, and different pancreatic stump closure techniques have been used to reduce the incidence. A network meta-analysis was undertaken to compare the most frequently performed pancreatic stump closure techniques after distal pancreatectomy and determine the technique associated with the lowest POPF rate. A systematic search of the Scopus, PubMed, MEDLINE and Embase databases was conducted to identify eligible RCTs. The primary outcome was the occurrence of clinically relevant POPF. Secondary outcomes were duration of operation, blood loss, intrabdominal collections, postoperative complications and 30-day mortality. Sixteen RCTs including 1984 patients and eight different pancreatic stump closure techniques were included in the network meta-analysis. Patch coverage of the pancreatic stump (round ligament or seromuscular patch) after stapler or suture closure ranked best, with the lowest rates of clinically relevant POPF, lowest volume of intraoperative blood loss, fewer intra-abdominal abscesses, and lower rates of overall complications and 30-day mortality. Round ligament patch closure outperformed seromuscular patch closure in preventing clinically relevant POPF with a significantly larger cohort for comparative analysis. Pancreaticoenteric anastomotic closure consistently ranked poorly for most reported postoperative outcomes. Patch coverage after stapler or suture closure has the lowest POPF rate and best outcomes among stump closure techniques after distal pancreatectomy.

Laparoscopic Vessel Clipping at Myomectomy - Uterine, Ovarian and Sampsons Artery

Video Objective To demonstrate the occlusion of three areas: the uterine artery, the round ligament and the infundibulopelvic ligament during myomectomy as a blood-sparing technique. Setting Two young patients presented with severe dysmenorrhea, AUB and subfertility. They underwent laparoscopic myomectomy, for whom the uterine artery, infundibulo-pelvic ligament and round ligament were occluded prior to the first uterine incision. Interventions After a survey, it was decided to use the lateral approach to uterine artery occlusion. The landmark was identified with traction on the medial umbilical ligament. The peritoneum was incised, and the ureter and uterine artery were exposed with careful blunt dissection. Temporary surgical clips were placed on bilateral uterine arteries. Subsequently, bilateral IP and round ligaments were similarly occluded. With devascularisation achieved, a linear incision was made over the myoma using a unipolar hook and carried through the serosa right to the myoma. Myometrium was sutured using the baseball technique. Myopia was removed by morcellation. Surgical clips were successfully removed from the uterine arteries and both IP and round ligaments. Peritoneal lavage was carried out, and Intercede barrier (Ethicon, Johnson & Johnson, Neuchatel, Switzerland) was placed. Blood loss was estimated by subtracting the instilled rinsing volume from the volume of fluid collected in the suction drain at the end of procedure. There were no post-operative complications. Conclusion Occlusion both the infundibulo-pelvic and round ligaments prior to laparoscopic myomectomy is a simple, reversible procedure, and does not significantly increase operative times. When used in conjunction with transient uterine artery occlusion, it may serve to further limit blood loss during surgery and hasten recovery. Larger studies are needed to define surgical outcomes, and recognize short and long term complications, if any.

2769 Laparoscopic Round Ligament Suspension for Dyspareunia in a Retroverted Uterus

Video Objective This video shows the steps of laparoscopic round ligament suspension used to neutralize the position of a retroverted uterus in order to relieve deep dyspareunia. Setting A 35 year-old nulliparous patient presented for gynecologic care due to dysmenorrhea and dyspareunia refractory to medical treatment. She was found to have a retroverted uterus and pain was reproduced with palpation of the fundus with an otherwise normal exam. After discussion of options for management she desired diagnostic laparoscopy with possible round ligament suspension to address her retroverted uterus. Interventions During laparoscopic survey significant retroversion of the uterus was confirmed with no other etiology for her pain identified. Laparoscopic round ligament suspension was completely in order to neutralize the angle of her uterus. There were no complications, the uterus was noted to remain axial at time of post-operative exam, and her dyspareunia was significantly improved. Conclusion Laparoscopic suspension of the round ligament is a simple, straightforward procedure that should be considered for patients with dyspareunia due to a retroverted uterus.

2953 Temporary Uterine Artery Ligation During Laparoscopic Myomectomy - Different Surgical Approaches

Video Objective Laparoscopic Uterine Artery Ligation may be performed during myomectomy in order to reduce the amount of blood loss during surgery. Setting Step-by-step video demonstration of three different techniques. Interventions Main steps of uterine artery ligation are described in detail as well as different laparoscopic variants to this procedure. Anterior Approach The impression of the uterine vessels can usually be seen anterior and laterally to the uterine cervix. After the identification of the path of the uterine arteries, the peritoneum of the anterior cul-de-sac is opened over the vessels and the uterine artery is carefully dissected next to the lateral border of the uterine cervix. This dissection must be extremely cautious because the uterine veins are very close to the artery. After the circumferential dissection of the artery, the temporary occlusion is conducted using 2-0 polyester suture. Posterior approach, lateral to the infundibulopelvic ligament For the ligation of the uterine artery posteriorly to the uterus and laterally to the pelvic infundibulum, the opening of the peritoneum of the broad ligament should start immediately below the round ligament, parallel to the external iliac vessels towards the base of the pelvic infundibulum. The avascular space is dissected by blunt dissection identifying the following landmarks: • Lateral: external iliac vessels; • Medial: pelvic infundibulum and the ureter attached to the peritoneum. The external iliac artery is dissected cranially in order to find the bifurcation of the common iliac artery and the internal iliac artery. The first medial branch of the anterior division of the internal iliac is normally the uterine artery. After dissection of the uterine artery it may be ligated according to the same technique described above. Conclusion Laparoscopic Uterine Artery legation may be performed during laparoscopic myomectomy to reduce intraoperative blood loss. According to surgical scenario, the surgeon may choose among one of the above-mentioned techniques to perform it.

1279 Total Laparoscopic Hysterectomy in an 18 Week Sized Uterus with Persistent Gestational Trophoblastic Disease

Video Objective To describe and illustrate an innovative minimally invasive surgical technique to allow a total laparoscopic hysterectomy with safe and feasible extraction of an 18 week sized uterus with gestational trophoblastic neoplasia (GTN). Setting The patient is a 44 year old G4P2012 with a diagnosis of GTN, status post dilation and evacuation with increasing b-hCG levels during follow-up. Workup for metastatic disease was negative. She completed childbearing and opted for a hysterectomy as definitive treatment. Interventions Intraoperatively, the uterus appeared to be 18 weeks in size. Laparoscopic dissection started by bilateral salpingectomy and transection of the utero-ovarian ligaments, preserving the ovaries. The broad ligament was then skeletonized, and the round ligaments were transected bilaterally. The bladder flap was created, and the uterine vessels were transected bilaterally using an advanced bipolar device. A sponge on a stick soaked in methylene blue was used to delineate the cervix and vagina. The cervix was then dilated to 14’’ and evacuation was performed using 12 suction. The suction continued until all products were removed and the uterus was significantly smaller in size. The colpotomy was performed and the uterus was extracted intact. Conclusion This is the first case in the literature to describe a minimally invasive technique that demonstrates a safe and feasible laparoscopic removal of an enlarged uterus and illustrates alternative extraction techniques to avoid laparotomy in GTN. In this case, a combination of laparoscopic transection of vascular pedicles followed by a dilation and evacuation was used prior to colpotomy. The addition of dilation and evacuation allowed us to reduce the overall size of the uterus and remove it intact through the vagina with minimal bleeding, avoiding unnecessary laparotomy. This allowed the patient to have a faster post-surgical recovery, minimal blood loss (EBL 20) and no hospitalization in comparison to standard laparotomy for persistent GTN.

1655 Laparoscopic Unification of Non Communicating Horn with Hemi-Uterus

Video Objective To demonstrate new idea of laparoscopic unification of functional non – communicating horn with hemi-uterus instead of removal to improve obstetric outcome in future. Setting an academic tertiary care hospital. A 14-year-old girl presented with complaints of pain in lower abdomen, on and off for 2 months. Her previous 2 cycles were regular; she had cyclic dysmenorrhoea since her menarche which was now become intolerable and continuous. Secondary sexual characteristic was normal. hormone profile normal and on local examination normal external genitalia found. A thin dilator passed into vagina to confirm patent vagina. ultrasound suggested a unicornuate hemi uterus and right non communicating horn with a turbid collection. MRI also confirm the same. Interventions On Hysteroscopy a small right uterine cavity with only one ostium on right. Cervical canal was normal with normal crypts. vagina also normal and spacious. On diagnostic laparoscopy: A unicornuate right hemi- uterus with a non-communicating left horn was noted on the right side of the round ligament, tube and ovary were seen normal with small hemi-uterus. On the left, small uterine horn seen with absent tube but normal ovary and round ligament attachment. First, we were planned resection of non-communicating horn as described in literature but after assessing the anatomical proximity and good size of horn and small size of hemi-uterus we decided for unification of both. After injecting diluted inj. vasopressin, linear medial incision given in full thickness of myometrium with monopolar energy and opening the cavity with scissors. Both the walls sutured together first posteriorly and then anteriorly in double layer with no. 1 polyglactin 910 suture. Conclusion Good normal size, shape and contour of uterus appreciated after completion of procedure. After surgery patient had one normal menses without any pain suggest success of surgery.

2924 Oophoropexy in Adolescent Patients

Video Objective This video demonstrates a technique of oophoropexy through plication of the utero-ovarian ligament to the round ligament. Setting The patient is a 13 year old P0 with a history of right ovarian torsion 10 months prior, for which she underwent laparoscopic detorsion without oophoropexy. She re-presented to the ED with two weeks of severe intermittent right lower abdominal pain, associated with nausea and vomiting. MRI abdomen/pelvis revealed twisting of the right ovarian pedicle. In addition, the right ovary was enlarged due to ovarian stromal edema, and there was peripheralization of the follicles. There was no ovarian cyst or mass. At the time of evaluation, the patient was not experiencing pain and she was clinically stable. She was suspected to have intermittent torsion. The patient and her parents were counseled on the option of observation and outpatient follow up versus surgical management with oophoropexy. They desired to proceed with surgical management. Interventions Oophoropexy was performed with a horizontal mattress of non-absorbable Polyester suture from the round ligament, through the mesosalpinx, and to the utero-ovarian ligament. Conclusion Evidence supports ovarian oophoropexy rather than oophorectomy for recurrent ovarian torsion in adolescents. Despite this the National Inpatient Sample (NIS) estimates 78% of adolescents underwent oophorectomy. We demonstrate a method of oophoropexy for recurrent ovarian torsion. The case patient has remained asymptomatic since her procedure. In conclusion, oophoropexy should be considered for adolescent patients with recurrent ovarian torsion to decrease risk of recurrence and to preserve fertility.

Training Model for Laparoscopic Salpingectomy using an Energy Device: Practice Before the Or

Video Objective To develop an animal tissue model that can provide training on the use of electrosurgical devices as well as serve as a benchmark for performing laparoscopic salpingectomy procedures by gynecologic trainees. Setting Laparoscopic salpingectomy is a milestone procedure for gynecologic trainees. Despite the prevalence of laparoscopic salpingectomy, there is not an established animal tissue model to provide training in this procedure. This limits opportunities to practice with laparoscopic electrosurgical devices prior to performing the procedure in the operating room. Interventions An existing model with porcine uterus was modified for the purpose of this study1. Copper wire simulated the round and utero-ovarian ligaments, and felt pads simulated the ovaries. Gynecologic trainees used a bipolar device (LigaSure) to perform laparoscopic salpingectomies on the model during a pilot study. Each salpingectomy simulation was recorded, to be graded by two blinded gynecologic surgeons using the Global Operative Assessment of Laparoscopic Skills (GOALS) and Objective Structured Assessment of Laparoscopic Salpingectomy (OSA-LS) and has been previously reported2. Each trainee completed a survey to provide feedback on the model. Conclusion The animal tissue model shows promise for training in laparoscopic salpingectomy. On the 5-point Likert scale, 8 trainees who had previously performed this procedure in the operating room rated overall satisfaction at 4.9, realism 4.4, tactility 4.5, tissue quality 4.5, model anatomy 4.6. Data will be further evaluated to assess construct validity amongst trainee levels.

1959 Laparoscopic Resection of Bladder and Uterine Cervix Endometriotic Nodule

Video Objective Laparoscopic resection of bladder endometriosis is associated to the benefits of a minimally invasive approach. In this video, we aim to describe the surgical strategy applied in the treatment of anterior compartment deep endometriosis with bladder and uterine cervix infiltration. Setting Academic and public hospital. Patients A 37-year-old patient, with dysmenorrhea since the menarche, dysuria and dyspareunia for the last 3 years, without improvement with medical treatment. Complementary exams showed a 2,18cm bladder endometriosis nodule with an extension to cervical and anterior isthmic region of 1,87cm, and a proximity to the ureters bilaterally. The patient desired possible future fertility. Interventions Laparoscopic approach for treatment of bladder and uterine lesion. Measurements and Main Results Laparoscopic surgery identified the limits of the lesion. Nodule affected the round ligament bilaterally, bladder, and uterine serous layer. Both ureters were dissected since iliac bifurcation until uterine vessels. Horizontal incision was performed on the bladder around the lesion until the foley catheter visualization to avoid de ureteral meatus. Vesicouterine space was dissected and an 5cm lesion compromising the uterine serous to the cervix was removed. Yabuki space was recognized during the nodulectomy. Vaginal closure was made primordially followed by the vesical suture using 0 and 2-0 polygactin respectively. Operation was successfully completed. Patient was discharged 5 days later. Foley catheter and prophylactic antibiotic were used for 10 days. Social, urinary and sexual activities with improvement in pain and better quality of life. Conclusion Urinary tract endometriosis is a rare disease, but when it occurs the bladder is the most affected site. Patients often complain of dysuria, hematuria, and chronic pelvic pain. Partial bladder cystectomy offers complete removal of endometriotic nodule promoting improvement of urinary symptoms and quality of life.

The Approach to Uterine Artery Ligation

Video Objective To demonstrate approaches to uterine artery ligation Setting Gynaecology department at a University Hospital. Interventions We demonstrate various methods of uterine artery ligation during complex gynaecological surgery. Conclusion Bleeding is a significant risk during procedures such as hysterectomies and myomectomies. During hysterectomy, the uterine artery is commonly ligated at the level of internal cervical os, though access may be limited in complex pathology such as fibroids, large uteri and adnexal masses. Furthermore, complications such as haemorrhage, ureteric and bladder injury may occur during attempts to secure difficult vascular pedicles. Such challenges can be overcome, by ligating the uterine artery at its vascular origin. During myomectomy, temporary occlusion using clips may help to reduce blood loss in selected cases. [1] We demonstrate simple and reproducible techniques of ligating the uterine artery at its origin. This valuable skill can be learnt by both novice as well as expert surgeons for utilisation during complex hysterectomy and myomectomy. We begin by performing ureterolysis by one of two approaches. [2] The posterior approach begins by opening the peritoneum overlying the ureter following visualisation at the pelvic side wall. Alternatively, a lateral approach is useful when views of the pelvic side wall are limited and includes division of the round ligament and peritoneum towards the base of infundibulopelvic ligament. Once ureterolysis is complete the obliterated umbilical artery is identified and followed into the pelvic side wall. Gentle traction can be used to confirm the ligament. Using open and spread, and traction and counter-traction techniques, the space lateral to the ureter and in front of the obliterated umbilical artery is gently dissected revealing the uterine artery. Using a Thunderbeat, we coagulated the vessels whilst maintaining distance from the ureter to avoid damage. One can use any preferred method for ligation including vessel sealing devices, sutures and temporary or permanent clips.

Laparoscopic Relocation of the Ovaries After Prior Transposition

Video Objective To describe the indications, surgical approaches and expected outcomes for ovarian transposition and highlight a case of ovarian relocation to the pelvis in a patient who underwent prior transposition. Setting A 34 year old patient with a history of metastatic spinal ependymoma underwent laparoscopic ovarian transposition prior to craniospinal radiation. Eleven years after her transposition, she was seen by reproductive endocrinology and infertility for preconception counseling and evaluation. Her follicle stimulating hormone levels were within normal limits, but her hysterosalpingogram demonstrated bilateral tubal isthmic occlusion. She was referred to minimally invasive gynecologic surgery for surgical consultation. Interventions The patient was taken to the operating room for operative laparoscopy, ovarian relocation to the pelvis and evaluation of her fallopian tubes. Intraoperative findings were notable for transposition of the bilateral ovaries and fallopian tubes to the lateral abdominal peritoneum. Adhesiolysis was performed to mobilize each ovary on its vascular pedicle. Without compromise to the ovarian blood supply, and in a tension-free manner, each ovary was sutured to the ipsilateral round ligament. Conclusion Laparoscopic ovarian transposition is an important surgical technique to aid preservation of ovarian function in reproductive aged women undergoing pelvic radiation. Gynecologic surgeons should be aware of the techniques to perform ovarian transposition, as well as relocation of the ovaries to the pelvis for future spontaneous or assisted reproduction. Knowledge of abdominal and pelvic anatomy, as well as proficiency in laparoscopic suturing are essential to perform ovarian transposition and relocation in a minimally invasive fashion.

Creation of a Neovagina: A Modified Davydov Approach

Video Objective This video presents a stepwise approach to the creation of a neovagina through a modified laparoscopic Davydov approach. Setting This procedure is most commonly performed for vaginal agenesis. First line treatment is self-dilation with multidisciplinary support. When first line treatment fails, a surgical approach to neovaginal creation is the Davydov procedure. This video illustrates the steps of a modified laparoscopic Davydov procedure for the creation of a neovagina in a patient with Mayer-Rokitansky-Kuster-Hauser Syndrome. Interventions The modified laparoscopic Davydov procedure is comprised of five steps: 1) define the anatomy (± salpingectomy), 2) create the neovaginal space, 3) line the neovagina with peritoneum, 4) dissect the pelvic sidewall, and 5) suture the neovagina over the stent. The modified laparoscopic approach involves round ligament preservation (instead of transection) for added vaginal support. It also involves transection of the utero-ovarian ligaments (instead of preservation) to keep ovaries in their anatomical location. More extensive pelvic sidewall dissection helps avoid tension on sidewall structures. Conclusion The Davydov procedure has high rates of sexual satisfaction and should be considered for the surgical creation of a neovagina.

1812 Excision of Ovarian Remnant

Video Objective Dissection techniques for removal of ovarian remnant. Setting Patients with persistent ovarian tissue and persistent pelvic pain after Oophorectomy. Interventions Excision of persistent ovarian tissue. Conclusion Ovarian remnant is a challenging problem as it is seen in patient whose primary surgery was complicated due to excessive adhesions or severe endometriosis. If the initial dissection was incomplete, a portion of ovarian tissue may remain adhered and continue to cause pelvic pain. This surgery requires dissection of pelvic side wall where remnant is most commonly isolated. Complete ureterolysis, separation of sigmoid colon from pelvic side wall and vagina, isolation of round ligament, IP ligament and uterine artery are the key steps while excising the ovarian residual tissue. This video demonstrates these key steps of dissection. Such patients will often be referred to a minimally invasive gynecologic surgeon who are trained in dissection of pelvic side wall with knowledge of retroperitoneal anatomy and can safely perform this complex dissection.

Safety and Efficiency of Laparoscopic Femoral Hernia Repair with Preserved Uterine Round Ligament.

To evaluate the efficiency and safety of the transabdominal preperitoneal (TAPP) technique with or without preserved uterine round ligament for the repair of femoral hernias (FHs), on the female patients treated at a single centre. Comparative-descriptive study. Department of General Surgery Center, Linyi People's Hospital, Shandong University, from January 2010 to December 2016. A total of 62 patients were randomly divided into traditional TAPP (T-TAPP) group and modified TAPP (M-TAPP) group, and all the procedures had been successfully completed. The operative time, recurrences and complications were investigated and compared. Twenty-six patients were randomised into T-TAPP group and 36 patients were randomised into M-TAPP group. There was no obvious difference in terms of age and body mass index between the two groups. The follow-up period was 24 to 90 months. Uterine prolapse occurred in five patients in T-TAPP group, but none in the M-TAPP group. There was significant difference between the two groups (p<0.05). There was also no significant difference in terms of postoperative infection or recurrence of hernia between the two groups nor was there any significant difference between the two groups in development of seroma, post-procedure pain and foreign body sensation during the long-term follow-up. The modified TAPP is a safe technique with a very low rate of recurrence and a low incidence of chronic pain, which retained the function of the uterine round ligament. It is an ideal method for the treatment of femoral hernia in female.

A Case of Endometriosis in the Right Inguinal Region Connected to the Round Ligament of the Uterus

A Case of Endometriosis in the Right Inguinal Region Connected to the Round Ligament of the Uterus

Differential diagnosis of fat-containing lesions in the inguinal canal using ultrasound.

Abdominal hernias are usually located in the inguinal canals. Differential diagnosis of hernias should consider other pathologies, which typically occur at this site. The aim of this review paper is to present fat-containing lesions located in the inguinal canal based on both our own experience and literature. The first part of the paper describes the embryogenesis and differences in the structure and content of male and female inguinal canal. The canal is clearly wider in men, which results from the presence of the spermatic cord and its components. The female canal contains only the narrow round ligament of the uterus. The second part of the paper discusses the incorrect use of the term “lipoma” for retroperitoneal fat, which penetrated into the lumen of the patent processus vaginalis – the authors using this term acknowledge its incorrectness. These lesions often coexist with oblique inguinal hernia and should be excised during a surgery as they may cause inguinal pain. As for other fat-containing inguinal pathologies, we discussed lipomatosis of the spermatic cord, liposarcoma and the greater omentum. Differential diagnosis of these lesions considers their echogenicity, echostructure and vascularity. Furthermore, attention was paid to the adipose tissue surrounding the lower epigastric vessels, which may be incorrectly localized in the inguinal canal. Finally, the importance of proper diagnostic methodology and knowledge of the inguinal anatomy for the correct ultrasonographic diagnosis was emphasized.

EP31.20: Ultrasound findings of extraperitoneal endometriosis of round ligament: a case report

EP31.20: Ultrasound findings of extraperitoneal endometriosis of round ligament: a case report

Four "fine" messages from four kinds of "fine" forgotten ligaments of the anterior abdominal wall: have you heard their voices?

On the posterior aspect of the anterior abdominal wall, there are four kinds of "fine" ligaments. They are: the round ligament of the liver, median umbilical ligament (UL), a pair of medial ULs, and a pair of lateral ULs. Four of them (the round ligament, median UL, and paired medial ULs) meet at the umbilicus because they originate from the contents of the umbilical cord. The round ligament of the liver originates from the umbilical vein, the medial ULs from the umbilical arteries, and the median UL from the urachus. These structures help radiologists identify right-sided round ligament (RSRL) (a rare, but surgically important normal variant), as well as to differentiate groin hernias. The ligaments can be involved in inflammation; moreover, tumors can arise from them. Unique symptoms such as umbilical discharge and/or location of pathologies relating to their embryology are important in diagnosing their pathologies. In this article, we comprehensively review the anatomy, embryology, and pathology of the "fine" abdominal ligaments and highlight representative cases with emphasis on clinical significance.

Endometriosis in an Indigenous African Women Population

Abstract Introduction Endometriosis is a condition in which endometrial tissue exists outside the endometrial cavity. It has a high prevalence in women living in developed countries and is reportedly the third most common cause of gynecologic hospitalization in the United States. It is believed to be rare among indigenous African women, although studies on its prevalence in this population are few. This study aims to determine the prevalence and clinical presentation of the condition in an indigenous African population. Methods This is a retrospective study of gynecological specimens received in the Histopathology Laboratory of Enugu State University Teaching Hospital from January 1, 2014, to December 31, 2018. Laboratory request forms and histopathology reports archived in the laboratory were retrieved and relevant information about patients diagnosed with endometriosis was extracted and analyzed by simple statistical methods. Results There were 25 diagnosed cases of endometriosis representing 0.9% of gynecological specimens received in the period. Patients’ average age was 38.4 ± 8.4 years while the peak age range was 31 to 40 years (n = 10; 40%). Myometrium was the most common site (n = 16; 64%), followed by the ovary (n = 5; 20%). The umbilicus, round ligament, broad ligament, and suprapubic region constituted 1 (4%), respectively. The most common symptoms were pelvic pain (36%) and abnormal uterine bleeding (32%) while recurrent ascites occurred in 1 (4%). There was associated primary and secondary infertility in 20% and 16% of cases, respectively. Recurrent abortion occurred in 4 (8%) of cases. The umbilical and suprapubic masses had symptoms, bleeding, and tender swelling, respectively, that synchronized with the patient’s menstrual cycle. Conclusion Endometriosis has a low prevalence in our population but occurs in rare sites. Women presenting with chronic pelvic pain and infertility and menstrual disorders should be evaluated for endometriosis. Population-based study is required to properly determine the actual prevalence of the condition in this population.